Application Fee: Rs 10/-

FORM ‘A’
Form of Application for Seeking Information Under the Right to Information Act, 2005
RTI Application No. ___________________
Date of Receipt ___________________
(For official use)
To
The Central Public Information Officer,
________________________________
________________________________

1. Full Name of the Applicant (in capital letters) : __________________________________

2. Complete Address (in capital letters) : __________________________________
__________________________________
Distt.____________State______________
Telephone Nos.
Office : ______________Residence:______________ Mobile: ___________________
Fax : ________________ E-mail Address: ______________________
3. Whether belong to BPL category : Yes/ No ___________________________
(If yes, please attach a copy of the BPL certificate, etc. Fees are exempted for citizens belonging to BPL category)
4. Details of Application Fee (Demand draft/ pay orders/ IPOs should be drawn in favor of ICAR-Unit, DCFR
payable at Bhimtal):
Cash Receipt/ DD/ IPO/ Date Name of the issuing Amount (in Rs.)
Bankers Cheque No. Bank/ Authority

5. Particulars of Information require : (Please enclosed separate sheet, if required)

6. How the applicant would like his information to be sent (Please tick) :
a) By Post b) By E-mail c) By Fax d) To be collected by Person

DECLARATION
This is to certify that I, __________________________________________ Son/ Daughter/ Wife of
________________________________________, am a citizen of India. Further, I state that the information
sought does not fall within the restrictions contained in Section 8 and 9 of the RTI Act, 2005 and to the best of my
knowledge it pertains to your office.

Date & Place: Signature of Applicant